City of Los Angeles

V18CAEOC(2010)

DeltaCare® USA

Provided by:

Delta Dental of California17871 Park Plaza Drive, Suite 200Cerritos, CA 90703

deltadentalins.com

Dental Health Care Program for Eligible Employees and Dependents

Combined Evidence of Coverage and Disclosure Form

CAEOC(2010) V18

EVIDENCE OF COVERAGEDISCLOSURE FORM

DeltaCare® USA Dental HMO Program

This booklet is a Combined Evidence of Coverage and Disclosure Form (“EOC”) for your DeltaCare USA Dental HMO Program (“Program”) provided by Delta Dental of California (“Delta Dental”). The Program has been established and is administered in accordance with the provisions of a Group Dental Service Contract (“Contract”) issued by Delta Dental.

THE EOC CONSTITUTES ONLY A SUMMARY OF THE PROGRAM. AS REQUIRED BY THE CALIFORNIA HEALTH & SAFETY CODE, THIS IS TO ADVISE YOU THAT THE CONTRACT MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF THE COVERAGE PROVIDED UNDER IT.

A COPY OF THE CONTRACT WILL BE FURNISHED UPON REQUEST. ANY DIRECT CONFLICT BETWEEN THE CONTRACT AND THE EOC WILL BE RESOLVED ACCORDING TO THE TERMS WHICH ARE MOST FAVORABLE TO YOU. READ THIS EOC CAREFULLY AND COMPLETELY. PERSONS WITH SPECIAL HEALTHCARE NEEDS SHOULD READ THE SECTION ENTITLED “SPECIAL NEEDS”.

A STATEMENT DESCRIBING DELTA DENTAL’S POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST.

PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW HOW TO OBTAIN DENTAL BENEFITS.

IMPORTANT: If you opt to receive dental services that are not covered services under this plan, a Contract Dentist may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the Dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call Customer Service at 800-422-4234 or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage document.

The telephone number where you may obtain information about Benefits is 800-422-4234.

Table of ContentsDefinitions .................................................................................................................... 1

Eligibility for Benefits ............................................................................................. 2

Prepayment Fees/Premiums ............................................................................... 3

How to use the DeltaCare USA Plan - Choice of Contract Dentist ......4

Continuity of Care ...................................................................................................4

Special Needs ............................................................................................................ 5

Facility Accessibility ............................................................................................... 5

Benefits, Limitations and Exclusions ................................................................ 5

Copayments and Other Charges ....................................................................... 5

Emergency Services ............................................................................................... 5

Specialist Services ...................................................................................................6

Second Opinion ........................................................................................................6

Claims for Reimbursement ...................................................................................6

Provider Compensation .........................................................................................6

Processing Policies .................................................................................................. 7

Coordination of Benefits ....................................................................................... 7

Enrollee Complaint Procedure ............................................................................ 7

Public Policy Participation by Enrollees .........................................................9

Renewal and Termination of Benefits ..............................................................9

Cancellation of Enrollment ...................................................................................9

Optional Continuation of Coverage (COBRA) ........................................... 10

Organ and Tissue Donation ................................................................................13

Description of Benefits and Copayments .................................................... 14

Limitations of Benefits .........................................................................................24

Exclusions of Benefits ..........................................................................................25

City of Los Angeles, #70635 CA10A - 00635 EOC - V18

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DefinitionsAs used in this booklet:

Benefits mean those dental services which are provided under the terms of the Group Dental Service Contract and described in this booklet.

Client means the applicant (employer or other organization) contracting to ob-tain Benefits for Eligible Employees.

Contract Dentist means a Dentist who provides services in general dentistry, and who has agreed to provide Benefits to Enrollees under this Program.

Contract Orthodontist means a Dentist who specializes in orthodontics, and who has agreed to provide Benefits to Enrollees under this Program.

Contract Specialist means a Dentist who provides Specialist Services and has agreed to provide Benefits to Enrollees under this Program.

Copayment means the amount charged to an Enrollee by a Contract Dentist for the Benefits provided under this Program.

Dentist means a duly licensed Dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are performed.

Domestic Partner means a domestic partnership shall exist between two people (regardless of their gender) and each of them shall be the domestic partner of the other if they complete, sign and file with the Personnel Department Benefits Division of City of Los Angeles an Affidavit of Domestic Partnership. A domes-tic partner is subject to the same terms and conditions as any other Dependent enrolled under this Contract.

Eligible Dependent means any dependent of an Eligible Employee who is eligible for Benefits as described in this booklet.

Eligible Employee means any employee or group member who is eligible for Benefits as described in this booklet.

Emergency Service means care provided by a Dentist to treat a dental condi-tion which manifests as a symptom of sufficient severity, including severe pain, such that the absence of immediate attention could reasonably be expected by the Enrollee to result in either: (i) placing the Enrollee's dental health in serious jeopardy, or (ii) serious impairment to dental functions.

Enrollee means an Eligible Employee ("Primary Enrollee") or an Eligible Depen-dent ("Dependent Enrollee") enrolled to receive Benefits.

Open Enrollment Period means the month of October preceding the annual commencement of the contract term.

Out-of-Network means treatment by a Dentist who has not signed an agreement with Delta Dental to provide Benefits under this Program.

Preauthorization means the process by which Delta Dental determines if a pro-cedure or treatment is a referable covered Benefit under the Enrollee's plan.

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Reasonable means that an Enrollee exercises prudent judgment in determining that a dental emergency exists and makes at least one attempt to contact his/her Contract Dentist to obtain Emergency Services and, in the event the Dentist is not available, makes at least one attempt to contact Delta Dental for assis-tance before seeking care from another Dentist.

Special Health Care Need means a physical or mental impairment, limitation or condition that substantially interferes with an Enrollee's ability to obtain Ben-efits. Examples of such a Special Health Care Need are 1) the Enrollee's inability to obtain access to the assigned Contract Dentist's facility because of a physical disability and 2) the Enrollee's inability to comply with the Contract Dentist's instructions during examination or treatment because of physical disability or mental incapacity.

Specialist Services mean services performed by a Dentist who specializes in the practice of oral surgery, endodontics, periodontics or pediatric dentistry, and which must be preauthorized in writing by Delta Dental.

Spouse means a person related to or a partner of the Primary Enrollee: - as defined and as may be required to be treated as a Spouse by the laws of

the state where this Contract is issued and delivered; - as defined and as may be required to be treated as a Spouse by the laws of

the state where the Primary Enrollee resides; and - as may be recognized by the Client.

Treatment In Progress means any single dental procedure, as defined by the CDT Code, that has been started while the Enrollee was eligible to receive Benefits, and for which multiple appointments are necessary to complete the procedure whether or not the Enrollee continues to be eligible for Benefits under the Del-taCare USA plan. Examples include: teeth that have been prepared for crowns, root canals where a working length has been established full or partial dentures for which an impression has been taken and orthodontics when bands have been placed and tooth movement has begun.

We, Us or Our means Delta Dental of California or the Administrator as appropri-ate.

Eligibility for BenefitsEligible Employees and Eligible Dependents receive Benefits as soon as they are enrolled in the Program. Subject to cancellation as provided under this Program, enrollment of Eligible Employees and Eligible Dependents is for a minimum pe-riod of one year.

You are eligible to enroll as an Eligible Employee if you meet the eligibility re-quirements defined by the Client.

Eligible Dependents become eligible on:1) the date you are eligible for coverage;2) as soon as an Eligible Dependent becomes your dependent, or at any time

subject to a change in legal custody or lawful order to provide Benefits.

Eligible Dependents include:1) spouse (unless legally separated or divorced) or Domestic Partner regard-

less of gender (until such partnership is terminated by either or both par-ties);

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2) children from birth up to age 26.

Children include natural children, stepchildren, adopted children, foster children and eligible children of a Domestic Partner. Grandchildren will be covered up to age 26 if the employee has legal custody and provides the City of Los Angeles with copies of the court documentation. Grandchildren will be covered up to age 26 if their parent is the employee's unmarried dependent child who meets the requirements as defined by the City of Los Angeles. Newborn children (includ-ing newborn adopted children) are covered from and after the moment of birth. Notice of birth must be received within 31 days after the date of birth for cover-age to continue beyond 31 days. Legally adopted children (other than newborns) are eligible from and after the moment the child is placed in the physical custody of the Eligible Employee for adoption.

An overage dependent child may be eligible if:1) he or she is incapable of self-sustaining employment because of a physically

or mentally disabling injury, illness or condition that began prior to reaching the limiting age;

2) he or she is chiefly dependent on you for support; and3) proof of dependent's disability is provided within 60 days of request. Such

requests will not be made more than once a year following a two year period after this dependent reaches the limiting age. Eligibility will continue as long as the dependent relies on you for support because of a physically or men-tally disabling injury, illness or condition that began before he or she reached the limiting age.

Dependents in active military service are not eligible.

If you and your spouse or domestic partner are both employees of the City of Los Angeles, the employee cannot enroll as both an employee and as a Depen-dent of their spouse or domestic partner. In such cases, they must both enroll as individuals. If the Eligible Employee and spouse or domestic partner have dependents then one must enroll as employee only and the other must enroll as an employee with dependents.

Medicare eligibility shall not affect the eligibility of an Eligible Member or an Eligible Dependent.

Prepayment Fees/PremiumsThis Program requires premiums to be paid to us. If you are required to pay all or any portion of the premiums, you will be advised of the amount prior to enroll-ment and it will be deducted from your earnings by payroll deduction, or you will be requested to pay it directly. The Client will be responsible for sending all payments of premiums to us except payments you are requested to pay directly. Should you voluntarily cancel enrollment and subsequently desire to re-enroll, all premiums retroactive to the date of cancellation (but not to exceed 12 months) must be paid before you can re-enroll.

We may cancel the Contract 30 days after written notice to the Client if monthly premiums are not paid when due. The Client will be given a 30 day grace period, which begins immediately following the last day of paid coverage, to pay the monthly premium. During that time, Delta Dental will continue to provide cover-age to Enrollees. If the premium remains unpaid at the end of the 30 day grace period, the Contractholder will notify you that coverage has terminated along with the date of termination.

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How to use the DeltaCare USA Plan - Choice of Contract DentistTo enroll in this Program, you must select a Contract Dentist for both yourself and any Dependent Enrollee from the list of Contract Dentists furnished during the enrollment process. Collectively, you and your Eligible Dependents may se-lect no more than three Contract Dentist facilities. If you fail to select a Contract Dentist or the Contract Dentist selected becomes unavailable, we will request the selection of another Contract Dentist or assign you to a Contract Dentist. You may change your assigned Contract Dentist by directing a request to the Customer Service department at 800-422-4234. In order to ensure that your Contract Dentist is notified and our eligibility lists are correct, changes in Con-tract Dentists must be requested prior to the 21st of the month for changes to be effective the first day of the following month.

Shortly after enrollment you will receive a DeltaCare USA membership packet that tells you the effective date of your Program and the address and telephone number of your Contract Dentist. After the effective date in your membership packet, you may obtain dental services which are Benefits. To make an ap-pointment, simply call your Contract Dentist's facility and identify yourself as a DeltaCare USA Enrollee. Initial appointments should be scheduled within four weeks unless a specific time has been requested. Inquiries regarding availability of appointments and accessibility of Dentists should be directed to the Customer Service department at 800-422-4234.

EACH ENROLLEE MUST GO TO HIS OR HER ASSIGNED CONTRACT DEN-TIST TO OBTAIN COVERED SERVICES, EXCEPT FOR SERVICES PROVIDED BY A SPECIALIST PREAUTHORIZED IN WRITING BY DELTA DENTAL, OR FOR EMERGENCY SERVICES AS PROVIDED IN EMERGENCY SERVICES. ANY OTHER TREATMENT IS NOT COVERED UNDER THIS PROGRAM.

If your assigned Contract Dentist's agreement with Delta Dental terminates, that Contract Dentist will complete (a) a partial or full denture for which final impres-sions have been taken, and (b) all work on every tooth upon which work has started (such as completion of root canals in progress and delivery of crowns when teeth have been prepared).

Continuity of CareCurrent Members:

You may have the right to the benefit of completion of care with your terminated Dentist for certain specified dental conditions. Please call Customer Service at 800-422-4234 to see if you may be eligible for this benefit. You may request a copy of our Continuity of Care Policy. You must make a specific request to con-tinue under the care of your terminated Dentist. We are not required to continue your care with that Dentist if you are not eligible under our policy or if we cannot reach agreement with your terminated Dentist on the terms regarding your care in accordance with California law.

New Members:

You may have the right to the qualified benefit of completion of care with an Out-of-Network Dentist for certain specified dental conditions. Please call the Customer Service department at 800-422-4234 to see if you may be eligible for this benefit. You may request a copy of our Continuity of Care Policy. You must make a specific request to continue under the care of your current Dentist. We are not required to continue your care with that Dentist if you are not eligible

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under our policy or if we cannot reach agreement with your Dentist on the terms regarding your care in accordance with California law. This policy does not apply to new Members of an individual subscriber contract.

Special NeedsIf an Enrollee believes he or she has a Special Health Care Need, the Enrollee should contact Delta Dental's Customer Service department at 800-422-4234. Delta Dental will confirm that a Special Health Care Need exists, and what ar-rangements can be made to assist the Enrollee in obtaining such Benefits. Delta Dental shall not be responsible for the failure of any Contract Dentist to comply with any law or regulation concerning structural office requirements that apply to a Dentist treating persons with Special Health Care Needs.

Facility AccessibilityMany facilities provide Delta Dental with information about special features of their offices, including accessibility information for patients with mobility impairments. To obtain information regarding facility accessibility, contact Delta Dental's Customer Service department at 800-422-4234.

Benefits, Limitations and ExclusionsThis Program provides the Benefits described in the Description of Benefits and Copayments subject to the limitations and exclusions. The services are per-formed as deemed appropriate by your attending Contract Dentist. A Contract Dentist may provide services either personally or through associated Dentists, technicians or hygienists who may lawfully perform the services.

Copayments and Other ChargesYou are required to pay any Copayments listed in the Description of Benefits and Copayments directly to the Dentist who provides treatment. Charges for broken appointments (unless notice is received by the Dentist at least 24 hours in advance or an emergency prevented such notice), and charges for visits after normal visiting hours are listed in the Description of Benefits and Copayments.

Emergency ServicesIf Emergency Services are needed, you should contact your Contract Dentist whenever possible. If you are a new Enrollee needing Emergency Services, but do not have an assigned Contract Dentist yet, contact Delta Dental's Customer Service department at 800-422-4234 for help in locating a Contract Dentist. Benefits for Emergency Services by an Out-of-Network Dentist are limited to necessary care to stabilize your condition and/or provide palliative relief when you:

1) have made a Reasonable attempt to contact the Contract Dentist and the Contract Dentist is unavailable or you cannot be seen within 24 hours of making contact; or

2) have made a Reasonable attempt to contact Delta Dental prior to receiv-ing Emergency Services, or it is Reasonable for you to access Emergency Services without prior contact with Delta Dental; or

3) reasonably believe that your condition makes it dentally/medically inappro-priate to travel to the Contract Dentist to receive Emergency Services.

Benefits for Emergency Services not provided by the Contract Dentist are lim-ited to a maximum of $100.00 per emergency, per Enrollee, less the applicable Copayment. If the maximum is exceeded, or the above conditions are not met,

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you are responsible for any charges for services by a provider other than your Contract Dentist.

Specialist ServicesSpecialist Services must be referred by the assigned Contract Dentist and preau-thorized in writing by Delta Dental. All preauthorized Specialist Services will be paid by us less any applicable Copayments. If an Enrollee is assigned to a dental school clinic for Specialist Services, those services may be provided by a Dentist, a dental student, a clinician or a dental instructor.

If the services of a Contract Orthodontist are needed, please refer to Orthodon-tics in the Description of Benefits and Copayments, and the limitations and exclu-sions to determine which procedures are covered under this Program.

Second OpinionYou may request a second opinion if you disagree with or question the diagnosis and/or treatment plan determination made by your Contract Dentist. Delta Den-tal may also request that you obtain a second opinion to verify the necessity and appropriateness of dental treatment or the application of Benefits.

Second opinions will be rendered by a licensed Dentist in a timely manner, ap-propriate to the nature of your condition. Requests involving cases of imminent and serious health threat will be expedited (authorization approved or denied within 72 hours of receipt of the request, whenever possible). For assistance or additional information regarding the procedures and timeframes for second opinion authorizations, contact Delta Dental's Customer Service department at 800-422-4234 or write to Delta Dental.

Second opinions will be provided at another Contract Dentist's facility, unless otherwise authorized by Delta Dental. Delta Dental will authorize a second opin-ion by an Out-of-Network provider if an appropriately qualified Contract Den-tist is not available. Delta Dental will only pay for a second opinion which Delta Dental has approved or authorized. You will be sent a written notification should Delta Dental decide not to authorize a second opinion. If you disagree with this determination, you may file a grievance with the plan or with the Department of Managed Health Care. Refer to the Enrollee Complaint Procedure section for more information.

Claims for ReimbursementClaims for covered Emergency Services or preauthorized Specialist Services should be submitted to Delta Dental within 90 days of the end of treatment. Valid claims received after the 90-day period will be reviewed if you can show that it was not reasonably possible to submit the claim within that time. The ad-dress for claims submission is: Claims Department, P.O. Box 1810, Alpharetta, GA 30023.

Provider CompensationA Contract Dentist is compensated by Delta Dental through monthly capitation (an amount based on the number of Enrollees assigned to the Dentist), and by Enrollees through required Copayments for treatment received. A Contract Spe-cialist is compensated by Delta Dental through an agreed-upon amount for each covered procedure, less the applicable Copayment paid by the Enrollee. In no event does Delta Dental pay a Contract Dentist or a specialist any incentive as an inducement to deny, reduce, limit or delay any appropriate treatment.

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In the event we fail to pay a Contract Dentist, you will not be liable to that Den-tist for any sums owed by us. By statute, the DeltaCare USA provider contract contains a provision prohibiting a Contract Dentist from charging an Enrollee for any sums owed by Delta Dental. Except for the provisions in Emergency Services, if you have not received Preauthorization for treatment from an Out-of-Network Dentist, and we fail to pay that Out-of-Network Dentist, you may be liable to that Dentist for the cost of services.

You may obtain further information concerning compensation by calling Delta Dental at the toll-free telephone number shown on the back cover of this book-let.

Processing PoliciesThe dental care guidelines for the DeltaCare USA Program explain to Contract Dentists what services are covered under the dental Contract. Contract Dentists will use their professional judgment to determine which services are appropri-ate for the Enrollee. Services performed by the Contract Dentist that fall under the scope of Benefits of the dental Program are provided subject to any Copay-ments. If a Contract Dentist believes that an Enrollee should seek treatment from a specialist, the Contract Dentist contacts Delta Dental for a determination of whether the proposed treatment is a covered benefit. Delta Dental will also de-termine whether the proposed treatment requires treatment by a specialist. An Enrollee may contact Delta Dental's Customer Service department at 800-422-4234 for information regarding the dental care guidelines for DeltaCare USA.

Coordination of BenefitsThis Program provides Benefits without regard to coverage by any other group insurance policy or any other group health benefits program if the other policy or program covers services or expenses in addition to dental care. Otherwise, Benefits provided under this Program by specialists or Out-of-Network Dentists are coordinated with such other group dental insurance policy or any group den-tal benefits program. The determination of which policy or program is primary shall be governed by the rules stated in the Contract.

If this plan is secondary, it will pay the lesser of:1) the amount that it would have paid in the absence of any other dental ben-

efit coverage, or2) the enrollee's total out-of-pocket cost payable under the primary dental

benefit plan as long as the benefits are covered under this plan.

An Enrollee shall provide to Delta Dental and Delta Dental may release to or obtain from any insurance company or other organization, any information about the Enrollee that is needed to administer coordination of benefits. Delta Dental shall, in its sole discretion, determine whether any reimbursement to an insur-ance company or other organization is warranted under these coordination of benefits provisions, and any such reimbursement paid shall be deemed to be Benefits under this Contract. Delta Dental will have the right to recover from a Dentist, Enrollee, insurance company or other organization, as Delta Dental chooses, the amount of any Benefit paid by Delta Dental which exceeds its obli-gations under these coordination of benefit provisions.

Enrollee Complaint ProcedureDelta Dental shall provide notification if any dental services or claims are denied, in whole or in part, stating the specific reason or reasons for the denial. If you have any complaint regarding eligibility, the denial of dental services or claims,

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the policies, procedures or operations of Delta Dental, or the quality of dental services performed by a Contract Dentist, you may call the Customer Service department at 800-422-4234, or the complaint may be addressed in writing to:

Quality Management Department P.O. Box 6050 Artesia, CA 90702

Written communication must include 1) the name of the patient, 2) the name, address, telephone number and identification number of the Primary Enrollee, 3) the name of the Client and 4) the Dentist's name and facility location.

For complaints involving an adverse benefit determination (e.g. a denial, modifi-cation or termination of a requested benefit or claim) you may file a request for review (a complaint) with Delta Dental at least 180 days after receipt of the ad-verse determination. Delta Dental's review will take into account all information, regardless of whether such information was submitted or considered initially. The review shall be conducted by a person who is neither the individual who made the original benefit determination, nor the subordinate of such individual. Upon request and free of charge, Delta Dental will provide you with copies of any pertinent documents that are relevant to the benefit determination, a copy of any internal rule, guideline, protocol, and/or explanation of the scientific or clinical judgment if relied upon in making the benefit determination. If the review of a denial is based in whole or in part on a lack of medical necessity, experimen-tal treatment, or a clinical judgment in applying the terms of the Contract, Delta Dental shall consult with a Dentist who has appropriate training and experience. If any consulting Dentist is involved in the review, the identity of such consulting Dentist will be available upon request.

Within 5 calendar days of the receipt of any complaint, including adverse benefit determinations as described above, the quality management coordinator will for-ward to you an acknowledgment of receipt of the complaint. Certain complaints may require that you be referred to a regional dental consultant for clinical evaluation of the dental services provided. Delta Dental will forward to you a de-termination, in writing, within 30 days of receipt of a complaint. If the complaint involves severe pain and/or imminent and serious threat to a patient's dental health, Delta Dental will provide the Enrollee written notification regarding the disposition or pending status of the complaint within three days.

If you have completed Delta Dental's grievance process, or you have been in-volved in Delta Dental's grievance procedure for more than 30 days, you may file a complaint with the California Department of Managed Health Care. You may file a complaint with the Department immediately in an emergency situation, which is one involving severe pain and/or imminent and serious threat to your health.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 800-422-4234 and use your health plan's grievance process before contacting the Department. Utilizing this griev-ance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical

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Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical neces-sity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emer-gency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), you may contact the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) for further review of the claim or if you have questions about the rights under ERISA. You may also bring a civil action under section 502(a) of ERISA. The address of the U.S. Department of Labor is: U.S. Department of Labor, Employee Benefits Security Administration, 200 Con-stitution Avenue, N.W. Washington, D.C. 20210.

Public Policy Participation by EnrolleesDelta Dental's Board of Directors includes Enrollees who participate in establish-ing Delta Dental's public policy regarding Enrollees through periodic review of Delta Dental's Quality Assessment program reports and communication from Enrollees. Enrollees may submit any suggestions regarding Delta Dental's public policy in writing to: Customer Service Department, P.O. Box 1803, Alpharetta, GA 30023.

Renewal and Termination of BenefitsThis Program renews on the anniversary of the contract term unless Delta Dental provides notice of a change in premiums or Benefits and the Client does not ac-cept the change. All Benefits terminate for any Enrollee as of the date that this Program is terminated, such person ceases to be eligible under the terms of this Program, or such person's enrollment is cancelled under the terms of this Pro-gram. We are not obligated to continue to provide Benefits to any such person in such event, except for completion of single procedures commenced while this Program was in effect.

Cancellation of EnrollmentSubject to any continued coverage option, an Eligible Employee's or Eligible Dependent's enrollment under this Program may be cancelled, or renewal of enrollment refused, in the following events:

1) immediately: a) upon loss of eligibility as described in this Evidence of Coverage; or

2) upon 30 days written notice if: a) the Contract is terminated or not renewed; b) the Premium is not paid by or on behalf of the Enrollee on the date due.

However, the Enrollee may continue to receive Benefits during the 30-day grace period and may be renewed at the end of the Contract Term upon payment of any unpaid Premium; or

c) Delta Dental demonstrates that the Enrollee committed fraud or an in-tentional misrepresentation of material fact in obtaining Benefits under the Program.

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Cancellation of a Primary Enrollee's enrollment, as described above, shall auto-matically cancel the enrollment of any of his or her Dependent Enrollees. Any cancellation is subject to the written notification requirements set forth in the Contract and in California law.

If you believe that enrollment has been improperly cancelled, rescinded or not renewed, you may request a review by the Director of the California Department of Managed Health Care of the State of California. Please refer to the Enrollee Complaint Procedure section for more information.

Optional Continuation of Coverage (COBRA)Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or you could be denied coverage entirely.

The City of Los Angeles Flex Plan (governed under Section 125 of the IRS Code) will abide by the rules defined by the IRS for Qualifying Events, relating to CO-BRA. Enrollees who lose coverage under this Program due to certain Qualifying Events, are entitled to continue coverage at their own expense if the group is subject to COBRA.

The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, per-taining to certain employers having 20 or more employees) requires that contin-ued health care coverage be made available to "Qualified Beneficiaries" who lose health care coverage under the group plan as a result of a "Qualifying Event." You may be entitled to continue coverage under this plan, at your expense, if certain conditions are met. The period of continued coverage depends on the Qualifying Event.

DEFINITIONS

The meaning of key terms used in this section is shown below.

Qualified Beneficiary means:1) Enrollees who are enrolled in the Delta Dental plan on the day before the

Qualifying Event, or2) a child who is born to or placed for adoption with you during the period of

continued coverage, provided such child is enrolled within 30 days of birth or placement for adoption.

Qualifying Event means any of the following events which, except for the elec-tion of this continued coverage, would result in a loss of coverage under the dental plan:

Event 1. the termination of employment (other than termination for gross mis-conduct) or the reduction in work hours, by your employer;

Event 2. your death;

Event 3. your divorce or legal separation from your spouse;

Event 4. your dependent's loss of dependent status under the plan; and

Event 5. as to your dependents only, your entitlement to Medicare.

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You or your means the Primary Enrollee.

PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA

Qualified Beneficiaries may continue coverage for 18 months following the month in which Qualifying Event 1 occurs.

This 18-month period can be extended for a total of 29 months, provided:1) a determination is made under Title II or Title XVI of the Social Security Act

that an individual is disabled on the date of the Qualifying Event or becomes disabled at any time during the first 60 days of continued coverage; and

2) notice of the determination is given to the employer during the initial 18 months of continued coverage and within 60 days of the date of the deter-mination.

This period of coverage will end on the first day of the month that begins more than 30 days after the date of the final determination that the disabled individual is no longer disabled. You must notify your employer or Delta Dental within 30 days of any such determination.

If, during the 18 months continuation period resulting from Qualifying Event 1, your dependents, who are Qualified Beneficiaries, experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for up to a total of 36 months (inclusive of the period continued under Qualifying Event 1).

Your dependents, who are Qualified Beneficiaries, may continue coverage for 36 months following the occurrence of Qualifying Events 2, 3, 4 or 5.

Under federal COBRA law only, when an employer has filed for bankruptcy under Title 11, United States Code, benefits may be substantially reduced or eliminated for retired employees and their dependents, or the surviving spouse of a de-ceased retired employee. If this benefit reduction or elimination occurs within one year before or one year after filing, it is considered a Qualifying Event. If the Primary Enrollee is a retiree, and has lost coverage because of this Qualify-ing Event, he or she may choose to continue coverage until his or her death. The Primary Enrollee's dependents who have lost coverage because of this Qualify-ing Event may choose to continue coverage for up to 36 months following the Primary Enrollee's death.

ELECTION OF CONTINUED COVERAGE

A Qualified Beneficiary will have 60 days from a Qualifying Event to give Delta Dental written notice of the election to continue coverage.

Upon written notice, Delta Dental will provide a Qualified Beneficiary with the necessary Benefits information, monthly premium charge, enrollment forms and instructions to allow election of continued coverage.

Failure to provide this written notice of election to Delta Dental within 60 days will result in the loss of the right to continue coverage.

A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the initial premium to Delta Dental, which includes the premium for each month since the loss of coverage. Failure to pay the required premium within the 45 days will result in the loss of the right to continue coverage and any premiums received after that will be returned to the Qualified Beneficiary.

- 12 - CA10A - 00635 EOC - V18

CONTINUED COVERAGE BENEFITS

The Benefits under the continued coverage will be the same as those provided to active employees and their dependents who are still enrolled in the dental plan. If the employer changes the coverage for active employees, the continued cover-age will change as well. Premiums will be adjusted to reflect the changes made.

TERMINATION OF CONTINUED COVERAGE

A Qualified Beneficiary's coverage will terminate at the end of the month in which any of the following events first occur:1) the allowable number of consecutive months of continued coverage is

reached;2) failure to pay the required premiums in a timely manner;3) the employer ceases to provide any group dental plan to its employees;4) the individual moves out of the plan's service area;5) the individual first obtains coverage for dental Benefits, after the date of

the election of continued coverage, under another group health plan (as an employee or dependent) which does not contain or apply any exclusion or limitation with respect to any pre-existing condition of such a person, if that pre-existing condition is covered under this plan; or

6) entitlement to Medicare.

Once continued coverage ends, it cannot be reinstated.

TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT

If the dental contract between the employer and Delta Dental terminates prior to the time that the continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary either 30 days prior to the termina-tion or when all Enrollees are notified, whichever is later, of the ability to elect continuation of coverage under the employer's subsequent dental plan, if any. The continuation coverage will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered under the Delta Dental plan had such plan with the former employer not terminated. The employer shall notify the successor plan in writing of the Qualified Beneficiaries receiving continuation coverage so they may be notified of how to continue coverage. The continuation coverage will terminate if a Qualified Beneficiary fails to comply with the requirements pertaining to enrollment in and payment of premiums to the new group benefit plan.

OPEN ENROLLMENT CHANGE OF COVERAGE

A Qualified Beneficiary may elect to change continuation coverage during any subsequent open enrollment period, if the employer has contracted with another plan to provide coverage to its active employees. The continuation coverage under the other plan will be provided only for the balance of the period that a Qualified Beneficiary would have remained under the Delta Dental plan.

- 13 - CA10A - 00635 EOC - V18

Organ and Tissue DonationDonating organs and tissue provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more mean-ingful lives. Currently, the need for organ transplants far exceeds availability. If you are interested in organ donation, please speak with your physician. Organ donation begins at the hospital, when a patient is pronounced brain dead and identified as a potential organ donor. An organ procurement organization will become involved to coordinate the activities.

SCHEDULE ADescription of Benefits and Copayments

EnrolleeCode Description Copay

S-A-DELTA-CA(2009) - 14 - CA10A - 00635 EOC - V18

The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the Program. Please refer to Schedule B for further clarification of Benefits. Enrollees should discuss all treat-ment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2018 procedure codes, descriptors or nomenclature that are under copyright by the Amer-ican Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

D0100-D0999 I. DIAGNOSTICD0120 Periodic oral evaluation - established patient .................................... No CostD0140 Limited oral evaluation - problem focused .......................................... No CostD0145 Oral evaluation for a patient under three years of age and

counseling with primary caregiver .......................................................... No CostD0150 Comprehensive oral evaluation - new or established patient ...... No CostD0160 Detailed and extensive oral evaluation - problem focused,

by report ............................................................................................................ No CostD0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) ................................... No CostD0171 Re-evaluation - post-operative office visit ................................................$5.00D0180 Comprehensive periodontal evaluation - new or

established patient ........................................................................................ No CostD0190 Screening of a patient .................................................................................. No CostD0191 Assessment of a patient .............................................................................. No CostD0210 Intraoral - complete series of radiographic images - limited to

1 series every 24 months .............................................................................. No CostD0220 Intraoral - periapical first radiographic image .................................... No CostD0230 Intraoral - periapical each additional radiographic image ............. No CostD0240 Intraoral - occlusal radiographic image ................................................. No CostD0250 Extraoral - 2D projection radiographic image created using a

stationary radiation source, and detector ............................................ No CostD0251 Extraoral posterior dental radiographic image .................................. No CostD0270 Bitewing - single radiographic image .................................................... No CostD0272 Bitewings - two radiographic images .................................................... No CostD0273 Bitewings three radiographic images .................................................... No CostD0274 Bitewings - four radiographic images - limited to 1 series

every 6 months................................................................................................ No CostD0277 Vertical bitewings - 7 to 8 radiographic images ................................ No CostD0330 Panoramic radiographic image ................................................................. No CostD0415 Collection of microorganisms for culture and sensitivity............... No CostD0425 Caries susceptibility tests ........................................................................... No CostD0460 Pulp vitality tests ............................................................................................ No CostD0470 Diagnostic casts.............................................................................................. No CostD0472 Accession of tissue, gross examination, preparation and

transmission of written report .................................................................. No CostD0473 Accession of tissue, gross and microscopic examination,

preparation and transmission of written report ................................. No CostD0474 Accession of tissue, gross and microscopic examination,

including assessment of surgical margins for presence of disease, preparation and transmission of written report ............... No Cost

S-A-DELTA-CA(2009) - 15 - CA10A - 00635 EOC - V18

D0601 Caries risk assessment and documentation, with a finding of low risk - 1 every 3 years .............................................................................. No Cost

D0602 Caries risk assessment and documentation, with a finding of moderate risk - 1 every 3 years ................................................................. No Cost

D0603 Caries risk assessment and documentation, with a finding of high risk - 1 every 3 years ............................................................................ No Cost

D0999 Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services) ...................................... No Cost

D1000-D1999 II. PREVENTIVED1110 Prophylaxis cleaning - adult - 1 D1110, D1120 or D4346 per

6 month period ............................................................................................... No CostD1110 Additional prophylaxis cleaning - adult (within the

6 month period) ................................................................................................ $45.00D1120 Prophylaxis cleaning - child - 1 D1110, D1120 or D4346 per 6 month period .................................... No CostD1120 Additional prophylaxis cleaning - child (within the

6 month period) ................................................................................................ $35.00D1206 Topical application of fluoride varnish - child to age 19;

1 D1206 or D1208 per 6 month period ................................................... No CostD1208 Topical application of fluoride - excluding varnish - child to

age 19; 1 D1206 or D1208 per 6 month period .................................... No CostD1310 Nutritional counseling for control of dental disease ........................ No CostD1330 Oral hygiene instructions ............................................................................ No CostD1351 Sealant - per tooth - limited to permanent molars through

age 15 .......................................................................................................................$5.00D1352 Preventive resin restoration in a moderate to high caries risk

patient - permanent tooth - limited to permanent molars through age 15 ......................................................................................................$5.00

D1353 Sealant repair - per tooth - limited to permanent molars through age 15 ......................................................................................................$5.00

D1354 Interim caries arresting medicament application - per tooth - child to age 19; 1 per 6 month period .................................................. No Cost

D1510 Space maintainer - fixed - unilateral ..........................................................$10.00D1515 Space maintainer - fixed - bilateral ............................................................$10.00D1520 Space maintainer - removable - unilateral ..............................................$10.00D1525 Space maintainer - removable - bilateral .................................................$10.00D1550 Re-cement or re-bond space maintainer .............................................. No CostD1555 Removal of fixed space maintainer ......................................................... No CostD1575 Distal shoe space maintainer - fixed - unilateral - child to

age 9 ......................................................................................................................$10.00

D2000-D2999 III. RESTORATIVE- Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases,

liners and acid etch procedures.- When there are more than six crowns in the same treatment plan, an Enrollee may

be charged an additional $100.00 per crown, beyond the 6th unit.- Replacement of crowns, inlays and onlays requires the existing restoration to be 5+

years old.D2140 Amalgam - one surface, primary or permanent ................................. No CostD2150 Amalgam - two surfaces, primary or permanent .............................. No CostD2160 Amalgam - three surfaces, primary or permanent............................ No CostD2161 Amalgam - four or more surfaces, primary or permanent............. No CostD2330 Resin-based composite - one surface, anterior ................................. No CostD2331 Resin-based composite - two surfaces, anterior ............................... No CostD2332 Resin-based composite - three surfaces, anterior ............................ No Cost

S-A-DELTA-CA(2009) - 16 - CA10A - 00635 EOC - V18

D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) ................................................................................. No Cost

D2390 Resin-based composite crown, anterior ............................................... No CostD2391 Resin-based composite - one surface, posterior ................................. $45.00D2392 Resin-based composite - two surfaces, posterior ............................... $55.00D2393 Resin-based composite - three surfaces, posterior ............................ $65.00D2394 Resin-based composite - four or more surfaces, posterior ..............$75.00D2510 Inlay - metallic - one surface ...................................................................... No CostD2520 Inlay - metallic - two surfaces ................................................................... No CostD2530 Inlay - metallic - three or more surfaces ............................................... No CostD2542 Onlay - metallic - two surfaces ................................................................. No CostD2543 Onlay - metallic - three surfaces .............................................................. No CostD2544 Onlay - metallic - four or more surfaces ............................................... No CostD2610 Inlay - porcelain/ceramic - one surface ..................................................$135.00D2620 Inlay - porcelain/ceramic - two surfaces ................................................$150.00D2630 Inlay - porcelain/ceramic - three or more surfaces ........................... $160.00D2642 Onlay - porcelain/ceramic - two surfaces ..............................................$150.00D2643 Onlay - porcelain/ceramic - three surfaces ...........................................$165.00D2644 Onlay - porcelain/ceramic - four or more surfaces ............................$175.00D2650 Inlay - resin-based composite - one surface ......................................... $85.00D2651 Inlay - resin-based composite - two surfaces ....................................... $95.00D2652 Inlay - resin-based composite - three or more surfaces ...................$115.00D2662 Onlay - resin-based composite - two surfaces .....................................$110.00D2663 Onlay - resin-based composite - three surfaces .................................$120.00D2664 Onlay - resin-based composite - four or more surfaces ..................$145.00D2710 Crown - resin-based composite (indirect) ............................................. $35.00D2712 Crown - ¾ resin-based composite (indirect) ........................................ $35.00D2720 Crown - resin with high noble metal .......................................................$155.00D2721 Crown - resin with predominantly base metal...................................... $55.00D2722 Crown - resin with noble metal................................................................... $95.00D2740 Crown - porcelain/ceramic ..........................................................................$195.00D2750 Crown - porcelain fused to high noble metal.......................................$195.00D2751 Crown - porcelain fused to predominantly base metal ..................... $95.00D2752 Crown - porcelain fused to noble metal .................................................$135.00D2780 Crown - ¾ cast high noble metal ..............................................................$170.00D2781 Crown - ¾ cast predominantly base metal ............................................ $70.00D2782 Crown - ¾ cast noble metal .........................................................................$110.00D2783 Crown - ¾ porcelain/ceramic .....................................................................$195.00D2790 Crown - full cast high noble metal ...........................................................$170.00D2791 Crown - full cast predominantly base metal ......................................... $70.00D2792 Crown - full cast noble metal ......................................................................$110.00D2794 Crown - titanium ..............................................................................................$195.00D2910 Re-cement or re-bond inlay, onlay, veneer or partial

coverage restoration ..................................................................................... No CostD2915 Re-cement or re-bond indirectly fabricated or prefabricated

post and core ................................................................................................... No CostD2920 Re-cement or re-bond crown .................................................................... No CostD2921 Reattachment of tooth fragment, incisal edge

or cusp (anterior) ........................................................................................... No CostD2929 Prefabricated porcelain/ceramic crown - primary

tooth - anterior ...................................................................................................$10.00D2930 Prefabricated stainless steel crown - primary tooth ........................ No CostD2931 Prefabricated stainless steel crown - permanent tooth .................. No CostD2932 Prefabricated resin crown - anterior primary tooth ............................. $15.00D2933 Prefabricated stainless steel crown with resin window

- anterior primary tooth ..................................................................................$10.00D2940 Protective restoration ................................................................................... No CostD2941 Interim therapeutic restoration - primary dentition ......................... No Cost

S-A-DELTA-CA(2009) - 17 - CA10A - 00635 EOC - V18

D2949 Restorative foundation for an indirect restoration ........................... No CostD2950 Core buildup, including any pins when required ............................... No CostD2951 Pin retention - per tooth, in addition to restoration ......................... No CostD2952 Post and core in addition to crown, indirectly fabricated

- includes canal preparation ....................................................................... No CostD2953 Each additional indirectly fabricated post - same tooth

- includes canal preparation ....................................................................... No CostD2954 Prefabricated post and core in addition to crown - base metal

post; includes canal preparation .............................................................. No CostD2957 Each additional prefabricated post - same tooth - base metal

post; includes canal preparation .............................................................. No CostD2971 Additional procedures to construct new crown under existing

partial denture framework ............................................................................. $19.00D2980 Crown repair necessitated by restorative material failure ................$10.00D2981 Inlay repair necessitated by restorative material failure ....................$10.00D2982 Onlay repair necessitated by restorative material failure ..................$10.00D2983 Veneer repair necessitated by restorative material failure ...............$10.00D2990 Resin infiltration of incipient smooth surface lesions - limited

to permanent molars through age 15 ..........................................................$5.00

D3000-D3999 IV. ENDODONTICSD3110 Pulp cap - direct (excluding final restoration) .................................... No CostD3120 Pulp cap - indirect (excluding final restoration) ................................ No CostD3220 Therapeutic pulpotomy (excluding final restoration) - removal

of pulp coronal to the dentinocemental junction and application of medicament ........................................................................ No Cost

D3221 Pulpal debridement, primary and permanent teeth ..............................$5.00D3222 Partial pulpotomy for apexogenesis - permanent tooth with

incomplete root development .................................................................. No CostD3230 Pulpal therapy (resorbable filling) - anterior, primary tooth

(excluding final restoration) ............................................................................$5.00D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth

(excluding final restoration) ............................................................................$5.00D3310 Root canal - endodontic therapy, anterior tooth

(excluding final restoration) ......................................................................... $45.00D3320 Root canal - endodontic therapy, premolar tooth

(excluding final restoration) .........................................................................$90.00D3330 Root canal - endodontic therapy, molar tooth

(excluding final restoration) ...................................................................... $205.00D3331 Treatment of root canal obstruction; non-surgical access .............. $45.00D3332 Incomplete endodontic therapy; inoperable, unrestorable

or fractured tooth ............................................................................................ $45.00D3333 Internal root repair of perforation defects ............................................. $45.00D3346 Retreatment of previous root canal therapy - anterior .....................$60.00D3347 Retreatment of previous root canal therapy - premolar ................ $105.00D3348 Retreatment of previous root canal therapy - molar .......................$220.00D3351 Apexification/recalcification - initial visit (apical

closure/calcific repair of perforations, root resorption, etc.).......... $70.00D3352 Apexification/recalcification - interim medication replacement

(apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)....................................................................... $45.00

D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical

closure/calcific repair of perforations, root resorption, etc.).......... $45.00D3410 Apicoectomy - anterior ............................................................................... No CostD3421 Apicoectomy - premolar (first root) ....................................................... No CostD3425 Apicoectomy - molar (first root) ............................................................. No Cost

S-A-DELTA-CA(2009) - 18 - CA10A - 00635 EOC - V18

D3426 Apicoectomy (each additional root) ...................................................... No CostD3427 Periradicular surgery without apicoectomy ........................................ No CostD3430 Retrograde filling - per root ....................................................................... No CostD3450 Root amputation - per root ........................................................................ No CostD3920 Hemisection (including any root removal), not including root

canal therapy ................................................................................................... No Cost

D4000-D4999 V. PERIODONTICS- Includes preoperative and postoperative evaluations and treatment under a local

anesthetic.D4210 Gingivectomy or gingivoplasty - four or more contiguous

teeth or tooth bounded spaces per quadrant ......................................$80.00D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth

or tooth bounded spaces per quadrant ..................................................$50.00D4212 Gingivectomy or gingivoplasty to allow access for restorative

procedure, per tooth .......................................................................................$50.00D4240 Gingival flap procedure, including root planing - four or more

contiguous teeth or tooth bounded spaces per quadrant ..............$80.00D4241 Gingival flap procedure, including root planing - one to three

contiguous teeth or tooth bounded spaces per quadrant ..............$50.00D4245 Apically positioned flap ..................................................................................$75.00D4249 Clinical crown lengthening - hard tissue ..................................................$75.00D4260 Osseous surgery (including elevation of a full thickness flap

and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant ...................................................................$175.00

D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant .................................................................. $140.00

D4263 Bone replacement graft - retained natural tooth - first site in quadrant.........................................................................................................$195.00

D4264 Bone replacement graft - retained natural tooth - each additional site in quadrant ............................................................................$60.00

D4270 Pedicle soft tissue graft procedure ..........................................................$195.00D4274 Mesial/distal wedge procedure, single tooth (when not

performed in conjunction with surgical procedures in the same anatomical area) ................................................................................... $45.00

D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft................................................................................................$195.00

D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site ................$195.00

D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months ................................................................................. No Cost

D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months ................................................................................. No Cost

D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation - 1 D1110, D1120 or D4346 per 6 month period .................................... No Cost

D4355 Full mouth debridement to enable comprehensive oral evaluation and diagnosis on subsequent visit - limited to 1 treatment in any 12 consecutive months ............................................ No Cost

D4910 Periodontal maintenance - limited to 1 treatment each 6 month period ............................................................................................... No Cost

S-A-DELTA-CA(2009) - 19 - CA10A - 00635 EOC - V18

D4910 Additional periodontal maintenance (within the 6 month period) ........................................................................ $55.00

D4921 Gingival irrigation - per quadrant ............................................................ No Cost

D5000-D5899 VI. PROSTHODONTICS (removable)- For all listed dentures and partial dentures, Copayment includes after delivery

adjustments and tissue conditioning, if needed, for the first six months after place-ment. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist's facility where the denture was originally delivered.

- Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months.

- Replacement of a denture or a partial denture requires the existing denture to be 5+ years old.

D5110 Complete denture - maxillary.................................................................... $100.00D5120 Complete denture - mandibular ............................................................... $100.00D5130 Immediate denture - maxillary ...................................................................$120.00D5140 Immediate denture - mandibular ..............................................................$120.00D5211 Maxillary partial denture - resin base (including any

conventional clasps, rests and teeth) .......................................................$80.00D5212 Mandibular partial denture - resin base (including any

conventional clasps, rests and teeth) .......................................................$80.00D5213 Maxillary partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth) ................................................................................................$120.00

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) ................................................................................................$120.00

D5221 Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth) ..............................................$80.00

D5222 Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth) ..............................................$80.00

D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) ................................................................................................$120.00

D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) ................................................................................................$120.00

D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) ................................................................................................$170.00

D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) .................................................................................$170.00

D5410 Adjust complete denture - maxillary ...................................................... No CostD5411 Adjust complete denture - mandibular ................................................. No CostD5421 Adjust partial denture - maxillary ............................................................ No CostD5422 Adjust partial denture - mandibular ....................................................... No CostD5511 Repair broken complete denture base, mandibular ............................ $15.00D5512 Repair broken complete denture base, maxillary ................................. $15.00D5520 Replace missing or broken teeth - complete denture

(each tooth) ..........................................................................................................$5.00D5611 Repair resin partial denture base, mandibular ....................................... $15.00D5612 Repair resin partial denture base, maxillary ........................................... $15.00D5621 Repair cast partial framework, mandibular ............................................. $15.00D5622 Repair cast partial framework, maxillary ................................................. $15.00D5630 Repair or replace broken clasp - per tooth ............................................. $15.00D5640 Replace broken teeth - per tooth .................................................................$5.00D5650 Add tooth to existing partial denture .........................................................$5.00D5660 Add clasp to existing partial denture - per tooth...................................$5.00

S-A-DELTA-CA(2009) - 20 - CA10A - 00635 EOC - V18

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) .....................................................................................$75.00

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) ................................................................................$75.00

D5710 Rebase complete maxillary denture ......................................................... $35.00D5711 Rebase complete mandibular denture .................................................... $35.00D5720 Rebase maxillary partial denture ............................................................... $35.00D5721 Rebase mandibular partial denture .......................................................... $35.00D5730 Reline complete maxillary denture (chairside) ................................... No CostD5731 Reline complete mandibular denture (chairside) .............................. No CostD5740 Reline maxillary partial denture (chairside) ......................................... No CostD5741 Reline mandibular partial denture (chairside) .................................... No CostD5750 Reline complete maxillary denture (laboratory) .................................. $35.00D5751 Reline complete mandibular denture (laboratory) ............................. $35.00D5760 Reline maxillary partial denture (laboratory) ........................................ $35.00D5761 Reline mandibular partial denture (laboratory) ................................... $35.00D5820 Interim partial denture (maxillary) - limited to 1 in any

12 consecutive months ................................................................................... $45.00D5821 Interim partial denture (mandibular) - limited to 1 in any

12 consecutive months ................................................................................... $45.00D5850 Tissue conditioning, maxillary ................................................................... No CostD5851 Tissue conditioning, mandibular .............................................................. No Cost

D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered

D6000-D6199 VIII. IMPLANT SERVICES - Not CoveredD6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and

each pontic constitutes a unit in a fixed partial denture [bridge])

- When a crown and/or pontic exceeds six units in the same treatment plan, an En-rollee may be charged an additional $100.00 per unit, beyond the 6th unit.

- Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old.

D6210 Pontic - cast high noble metal ...................................................................$170.00D6211 Pontic - cast predominantly base metal ................................................. $70.00D6212 Pontic - cast noble metal ..............................................................................$110.00D6240 Pontic - porcelain fused to high noble metal .......................................$195.00D6241 Pontic - porcelain fused to predominantly base metal ..................... $95.00D6242 Pontic - porcelain fused to noble metal .................................................$135.00D6245 Pontic - porcelain/ceramic ..........................................................................$195.00D6250 Pontic - resin with high noble metal ........................................................$155.00D6251 Pontic - resin with predominantly base metal ...................................... $55.00D6252 Pontic - resin with noble metal ................................................................... $95.00D6600 Retainer inlay - porcelain/ceramic, two surfaces ................................$150.00D6601 Retainer inlay - porcelain/ceramic, three or more surfaces .......... $160.00D6602 Retainer inlay - cast high noble metal, two surfaces ....................... $100.00D6603 Retainer inlay - cast high noble metal, three or more surfaces ... $100.00D6604 Retainer inlay - cast predominantly base metal, two surfaces .... No CostD6605 Retainer inlay - cast predominantly base metal, three

or more surfaces ............................................................................................. No CostD6606 Retainer inlay - cast noble metal, two surfaces ...................................$40.00D6607 Retainer inlay - cast noble metal, three or more surfaces ...............$40.00D6608 Retainer onlay - porcelain/ceramic, two surfaces ..............................$150.00D6609 Retainer onlay - porcelain/ceramic, three or more surfaces ..........$165.00D6610 Retainer onlay - cast high noble metal, two surfaces ...................... $100.00D6611 Retainer onlay - cast high noble metal, three or more surfaces..$100.00

S-A-DELTA-CA(2009) - 21 - CA10A - 00635 EOC - V18

D6612 Retainer onlay - cast predominantly base metal, two surfaces ... No CostD6613 Retainer onlay - cast predominantly base metal, three

or more surfaces ............................................................................................. No CostD6614 Retainer onlay - cast noble metal, two surfaces ..................................$40.00D6615 Retainer onlay - cast noble metal, three or more surfaces ..............$40.00D6720 Retainer crown - resin with high noble metal ......................................$155.00D6721 Retainer crown - resin with predominantly base metal .................... $55.00D6722 Retainer crown - resin with noble metal ................................................. $95.00D6740 Retainer crown - porcelain/ceramic ........................................................$195.00D6750 Retainer crown - porcelain fused to high noble metal .....................$195.00D6751 Retainer crown - porcelain fused to predominantly base metal ... $95.00D6752 Retainer crown - porcelain fused to noble metal ...............................$135.00D6780 Retainer crown - ¾ cast high noble metal ............................................$170.00D6781 Retainer crown - ¾ cast predominantly base metal .......................... $70.00D6782 Retainer crown - ¾ cast noble metal .......................................................$110.00D6783 Retainer crown - ¾ porcelain/ceramic ....................................................$195.00D6790 Retainer crown - full cast high noble metal ..........................................$170.00D6791 Retainer crown - full cast predominantly base metal ........................ $70.00D6792 Retainer crown - full cast noble metal .....................................................$110.00D6930 Re-cement or re-bond fixed partial denture ....................................... No CostD6940 Stress breaker .................................................................................................. No CostD6980 Fixed partial denture repair necessitated by restorative

material failure ....................................................................................................$10.00

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY- Includes preoperative and postoperative evaluations and treatment under a local

anesthetic.D7111 Extraction, coronal remnants - primary tooth .................................... No CostD7140 Extraction, erupted tooth or exposed root (elevation and/or

forceps removal) ............................................................................................ No CostD7210 Extraction, erupted tooth requiring removal of bone and/or

sectioning of tooth, and including elevation of mucoperiosteal flap if indicated .................................................................................................. $15.00

D7220 Removal of impacted tooth - soft tissue ................................................ $25.00D7230 Removal of impacted tooth - partially bony .........................................$50.00D7240 Removal of impacted tooth - completely bony ................................... $70.00D7241 Removal of impacted tooth - completely bony, with unusual

surgical complications....................................................................................$90.00D7250 Removal of residual tooth roots (cutting procedure) ...................... No CostD7251 Coronectomy - intentional partial tooth removal ................................$90.00D7270 Tooth reimplantation and/or stabilization of accidentally

evulsed or displaced tooth ...........................................................................$50.00D7280 Exposure of an unerupted tooth ................................................................ $85.00D7282 Mobilization of erupted or malpositioned tooth to aid eruption .. $85.00D7283 Placement of device to facilitate eruption of impacted tooth ..... No CostD7286 Incisional biopsy of oral tissue - soft - does not include

pathology laboratory procedures ........................................................... No CostD7310 Alveoloplasty in conjunction with extractions - four or more

teeth or tooth spaces, per quadrant....................................................... No CostD7311 Alveoloplasty in conjunction with extractions - one to three

teeth or tooth spaces, per quadrant....................................................... No CostD7320 Alveoloplasty not in conjunction with extractions - four or

more teeth or tooth spaces, per quadrant ........................................... No CostD7321 Alveoloplasty not in conjunction with extractions - one to

three teeth or tooth spaces, per quadrant ........................................... No CostD7450 Removal of benign odontogenic cyst or tumor - lesion

diameter up to 1.25 cm ................................................................................. No Cost

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D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm .................................................................. No Cost

D7471 Removal of lateral exostosis (maxilla or mandible) .......................... No CostD7472 Removal of torus palatinus ......................................................................... No CostD7473 Removal of torus mandibularis ................................................................. No CostD7510 Incision and drainage of abscess - intraoral soft tissue .................. No CostD7960 Frenulectomy - also known as frenectomy or frenotomy

- separate procedure not incidental to another procedure ........... No CostD7970 Excision of hyperplastic tissue - per arch ...............................................$50.00D7971 Excision of pericoronal gingiva...................................................................$50.00

D8000-D8999 XI. ORTHODONTICS- The listed Copayment for each phase of orthodontic treatment (limited, interceptive

or comprehensive) covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply.

- The Retention Copayment includes adjustments and/or office visits up to 24 months.

Pre and post orthodontic records include: The benefit for pre-treatment records and diagnostic

services includes: ........................................................................................... $200.00

D0210 Intraoral - complete series of radiographic imagesD0322 Tomographic surveyD0330 Panoramic radiographic imageD0340 2D cephalometric radiographic image - acquisition,

measurement and analysisD0350 2D oral/facial photographic images obtained intraorally

or extraorallyD0351 3D photographic imageD0470 Diagnostic casts The benefit for post-treatment records includes: ............................... $70.00D0210 Intraoral - complete series of radiographic imagesD0470 Diagnostic casts

D8010 Limited orthodontic treatment of the primary dentition .............. $950.00D8020 Limited orthodontic treatment of the transitional dentition

- child or adolescent to age 19 ................................................................. $950.00D8030 Limited orthodontic treatment of the adolescent dentition

- adolescent to age 19 ................................................................................. $950.00D8040 Limited orthodontic treatment of the adult dentition - adults,

including covered dependent adult children ..................................... $1,150.00D8050 Interceptive orthodontic treatment of the primary dentition ..... $950.00D8060 Interceptive orthodontic treatment of the

transitional dentition .................................................................................... $950.00D8070 Comprehensive orthodontic treatment of the transitional

dentition - child or adolescent to age 19 .......................................... $1,000.00D8080 Comprehensive orthodontic treatment of the adolescent

dentition - adolescent to age 19 ........................................................... $1,000.00D8090 Comprehensive orthodontic treatment of the adult dentition

- adults, including covered dependent adult children ..................$1,350.00D8660 Pre-orthodontic treatment examination to monitor growth

and development ............................................................................................. $25.00D8680 Orthodontic retention (removal of appliances, construction

and placement of removable retainers) ................................................ $275.00D8681 Removable orthodontic retainer adjustment ...................................... No CostD8999 Unspecified orthodontic procedure, by report - includes

treatment planning session ........................................................................ $100.00

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D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICESD9110 Palliative (emergency) treatment of dental pain

- minor procedure ...............................................................................................$5.00D9211 Regional block anesthesia .......................................................................... No CostD9212 Trigeminal division block anesthesia ...................................................... No CostD9215 Local anesthesia in conjunction with operative

or surgical procedures ................................................................................. No CostD9219 Evaluation for deep sedation or general anesthesia ........................ No CostD9222 Deep sedation/general anesthesia - first 15 minutes .........................$80.00D9223 Deep sedation/general anesthesia - each subsequent

15 minute increment ........................................................................................$80.00D9239 Intravenous moderate (conscious) sedation/analgesia

- first 15 minutes ...............................................................................................$80.00D9243 Intravenous moderate (conscious) sedation/analgesia - each

subsequent 15 minute increment ...............................................................$80.00D9310 Consultation - diagnostic service provided by dentist or

physician other than requesting dentist or physician...................... No CostD9311 Consultation with medical health care professional ........................ No CostD9430 Office visit for observation (during regularly scheduled hours)

- no other services performed .......................................................................$5.00D9440 Office visit - after regularly scheduled hours ........................................$20.00D9450 Case presentation, detailed and extensive treatment planning .. No CostD9932 Cleaning and inspection of removable complete

denture, maxillary .......................................................................................... No CostD9933 Cleaning and inspection of removable complete

denture, mandibular ...................................................................................... No CostD9934 Cleaning and inspection of removable partial

denture, maxillary .......................................................................................... No CostD9935 Cleaning and inspection of removable partial

denture, mandibular ...................................................................................... No CostD9940 Occlusal guard, by report - limited to 1 in 3 years ............................... $95.00D9943 Occlusal guard adjustment ...........................................................................$10.00D9951 Occlusal adjustment, limited .......................................................................$20.00D9952 Occlusal adjustment, complete ..................................................................$40.00D9975 External bleaching for home application, per arch; includes

materials and fabrication of custom trays - limited to one bleaching tray and gel for two weeks of self-treatment ..................$125.00

D9986 Missed appointment - without 24 hour notice - per 15 minutes of appointment time - up to an overall maximum of $40.00 ..........$10.00

D9987 Canceled appointment - without 24 hour notice - per 15 minutes of appointment time - up to an overall maximum of $40.00 ..............................................................................................................$10.00

D9991 Dental case management - addressing appointment compliance barriers ....................................................................................... No Cost

D9992 Dental case management - care coordination ................................... No CostD9995 Teledentistry - synchronous; real-time encounter ............................ No CostD9996 Teledentistry - asynchronous; information stored and

forwarded to dentist for subsequent review ....................................... No Cost

If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized by Delta Dental. The Enrollee pays the Copayment specified for such services.

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SCHEDULE BLimitations of Benefits1. The frequency of certain Benefits is limited. All frequency limitations are listed in

Schedule A, Description of Benefits and Copayments.

2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $100.00 above the listed Copayment for each of these services after the sixth unit has been provided.

3. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241).

4. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an indi-vidual basis.

5. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on the Contract Orthodon-tist's usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged.

6. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA Program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees sub-ject to the provisions of their prior dental plan. Delta Dental is financially respon-sible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

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Exclusions of Benefits1. Any procedure that is not specifically listed under Schedule A, Description of

Benefits and Copayments.

2. Any procedure that in the professional opinion of the Contract Dentist:

a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or

b. is inconsistent with generally accepted standards for dentistry.

3. Services solely for cosmetic purposes, with the exception of procedure D9975 (External bleaching for home application, per arch), or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth abnormalities.

4. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age.

5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges).

6. Procedures, appliances or restoration if the purpose is to change vertical dimen-sion, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ).

7. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial den-tures.

8. Implant-supported dental appliances and attachments, implant placement, main-tenance, removal and all other services associated with a dental implant.

9. Consultations for non-covered benefits.

10. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a Contract Orthodontist except for Emergency Services as described in the Contract and/or Evidence of Coverage.

11. All related fees for admission, use, or stays in a hospital, out-patient surgery cen-ter, extended care facility, or other similar care facility.

12. Prescription drugs.

13. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee's eligibility with the DeltaCare USA Program. Ex-amples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics unless quali-fied for the orthodontic treatment in progress provision.

14. Lost, stolen or broken orthodontic appliances.

15. Changes in orthodontic treatment necessitated by accident of any kind.

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16. Myofunctional and parafunctional appliances and/or therapies, with the exception of procedure D9940 (occlusal guard, per report).

17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orth-odontic appliances.

18. Treatment or appliances that are provided by a Dentist whose practice special-izes in prosthodontic services.

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Delta Dental ID card, or 1-800-422-4234.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Delta Dental o al 1-800-422-4234.

Delta Dental ID / 1-800-422-4234

If you have any questions or need additional informa-tion, call or write:

Toll Free800-422-4234

Administered by:Delta Dental of California17871 Park Plaza Drive, Suite 200Cerritos, CA 90703

110373_EOC_CA10A_70635_V18_11.17.2017